Emergency Medical Minute

Author: Jared Scott, MD Educational Pearls: EKG changes do not necessarily correlate to degree of hyperkalemia Traditional progression through peaked T-waves, flattened p-waves, QRS widening, and then sine-waves before asystole References Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. 2000;18:721–729.

Author: Erik Verzemnieks, MD Educational Pearls: In the panic of a precipitous ED delivery, remember: Warm. Dry. Stim. It will solve most of your problems in most scenarios Start compressions if heart rate is less than 60 Put the pulse ox on the right hand - it may make a difference as it is preductal Editor's note: detecting a heart rate can be tough in a newborn - you can feel the umbilical stump or just listen with your stethoscope References Gary Weiner & Jeanette Zaichkin. Textbook of Neonatal Resuscitation (NRP), 7th Ed, 2016. American Academy of Pediatrics & American Heart Association.

Author: Michael Hunt, MD Educational Pearls: Here is a list of some very toxic natural substances: #5: Tetrodotoxin: Found in pufferfish and other aquatic species #4: Ricin: made from castor beans #3: Mercury: natural element absorbable through skin and gloves #2: Batrachotoxin: found on poison dart frogs #1: Botulinum toxin: produced by Clostridium botulinum and causes a descending paralysis Editor's note: batrachotoxin is thought to be accumulated by the beatles and other insects dart frogs eat - those in captivity therefore are not poisonous References https://theconversation.com/handle-with-care-the-worlds-five-deadliest-poisons-56089

Author: Aaron Lessen, MD Educational Pearls: Non-blinded randomized study assessing 30-day mortality benefit from plasma-first resuscitation in patients at risk hemorrhagic shock Study involved aeromedical transport of trauma patients 30-day mortality 23.2 % in intervention group vs. 33.0% in standard care group Editor's note: a similar study published in Lancet at the same time showed no mortality benefit from prehospital administration of plasma in a slightly different population which had much shorter ground transport times a major trauma center References Sperry JL, Guyette FX, Brown JB, Yazer MH, Triulzi DJ, Early-Young BJ, Adams PW, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Duane TM, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Rosengart MR, Forsythe RM, Billiar TR, Yealy DM, Peitzman AB, Zenati MS; PAMPer Study Group.. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326. doi: 10.1056/NEJMoa1802345.

Podcast # 367: Digital Necrosis after Epinephrine Drip Author: Jared Scott, MD. Educational Pearls: Make sure to monitor for limb ischemia in all patients on vasopressors Good reminder that vasopressors are not risk free - use them only on patients that need them! References Daroca-Pérez, R., & Carrascosa, M. F. . Digital necrosis: a potential risk of high-dose norepinephrine. Therapeutic Advances in Drug Safety. 2017. 8(8), 259–261. http://doi.org/10.1177/2042098617712669.

Podcast # 366: Ehlers Danlos Author: Gretchen Hinson, MD. Educational Pearls: Heritable mutation in collagen synthesis and expression commonly resulting in joint hyperextension and skin elasticity. Vascular type can result in aneurysm formation and rupture in young patients. Patients are also at risk for spontaneous bowel rupture. Pregnant women can present with uterine rupture. References Byers PH, Murray ML (2012). "Heritable collagen disorders: the paradigm of Ehlers–Danlos syndrome". Journal of Investigative Dermatology. 132 (E1): E6–11. Pepin MG, Byers PH. Ehlers-Danlos Syndrome Type IV. In: Pagon RA, Bird TD, Dolan CR, et al., eds. GeneReviews [Internet]. Seattle (WA): University of Washington, Seattle; 1993-. Yoneda, A., Okada, K., Okubo, H., Matsuo, M., Kishikawa, H., Naing, B. T., … Shimada, T. (2014). Spontaneous Colon Perforations Associated with a Vascular Type of Ehlers-Danlos Syndrome. Case Reports in Gastroenterology, 8(2), 175–181. http://doi.org/10.1159/000363373

Author: Erik Verzemnieks, MD Educational Pearls: Single study in Japan demonstrated possible effectiveness of renal colic trigger point Patients had injection at the area of maximal tenderness on palpation of the flank Compared to a muscle relaxer, injection of local anesthetic at the trigger point had faster time to pain relief and fewer rescue therapies References Iguchi, M et al. Randomized trial of trigger point injection for renal colic. International Journal of Urology. 2002. 9(9): 475-479

Author: Peter Bakes, MD Educational Pearls: Pericarditis, LBBB, LVH and left ventricular aneurysms can all present with ST elevation. Ventricular aneurysm will present days after a cardiac event with ST elevation and Q waves in the affected leads. Ventricular aneurysms may cause papillary muscle dysfunction with a resultant holosystolic murmur and even heart failure. References Victor F. Froelicher; Jonathan Myers (2006). Exercise and the heart. Elsevier Health Sciences. pp. 138–. ISBN 978-1-4160-0311-3. Nagle RE, Williams DO. (1974) Proceedings: Natural history of ventricular aneurysm without surgical treatment. British Heart Journal, 36:1037.

Educational Pearls: Recent study has shown adjunctive ketamine can be useful in setting of alcohol withdrawal. Ketamine was associated with a decrease in the amount of benzodiazepines needed, likelihood of intubation, and a decrease in ICU length of stay by 3 days. For patients with benzodiazepine resistance, ketamine was shown to have symptom relief in an hour and decreased rate of benzodiazepine infusion. References Pizon A, Lynch M, Benedict N, et al. 2018. Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal. Critical Care Medicine. 46(8):e768-e771. Shah, P., McDowell, M., Ebisu, R. et al. J. Med. Toxicol. (2018). https://doi.org/10.1007/s13181-018-0662-8

Author: John Winkler, MD Educational Pearls: Tall flowering plant with phototoxic sap Direct skin contact with the sap can cause the skin to become photosensitive Severe blisters and even burns can result References Diebel, Matthew (18 June 2018). "Giant Hogweed, a Plant That Can Cause Burns and Blindness, Found in Virginia". USA Today.